What is the treatment for dyshidrotic eczema?

Treatment of Dyshidrotic Eczema (Pompholyx)

Start with medium to high potency topical corticosteroids applied twice daily to affected areas as first-line therapy, using the least potent preparation that effectively controls symptoms. 1, 2

First-Line Treatment Approach

Topical Corticosteroids

• Apply medium to high potency topical corticosteroids (such as betamethasone dipropionate or clobetasol propionate for severe flares) no more than twice daily until symptoms improve. 2
• Once acute vesiculation and pruritus resolve, taper to maintenance therapy with intermittent use (twice weekly) to prevent relapses. 2
• Use potent and very potent preparations with caution and for limited periods only due to risk of pituitary-adrenal axis suppression. 1, 2
• When possible, implement short "steroid holidays" to minimize long-term side effects. 1

Essential Adjunctive Skin Care

• Apply emollients liberally after bathing to provide a surface lipid film that retards evaporative water loss from the epidermis. 1, 2
• Replace regular soaps with dispersible cream as a soap substitute, as soaps and detergents remove natural skin lipids and worsen the condition. 2
• Regular bathing is beneficial for both cleansing and hydrating the skin. 1

Trigger Avoidance

• Avoid extremes of temperature and irritant clothing such as wool; cotton clothing is preferred. 2
• Keep nails short to minimize trauma from scratching and reduce secondary infection risk. 2
• Consider metal allergy as a potential etiologic factor, particularly in refractory cases, as metal allergen removal may improve symptoms. 3

Managing Secondary Infections

Bacterial Superinfection

• Watch for signs of bacterial infection: increased crusting, weeping, or pustules. 1
• Flucloxacillin is the first-line antibiotic for Staphylococcus aureus, the most common pathogen. 2
• Use erythromycin when there is resistance to flucloxacillin or in patients with penicillin allergy. 2
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently. 1

Viral Superinfection (Eczema Herpeticum)

• If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 1
• Initiate oral acyclovir early in the disease course. 1, 2
• In ill, feverish patients, administer acyclovir intravenously. 1

Second-Line Treatment Options

Topical Calcineurin Inhibitors

• Consider tacrolimus 0.1% ointment applied once daily to affected areas as a steroid-sparing agent, particularly useful where prolonged steroid use is concerning. 2
• This option is especially valuable for maintenance therapy after initial corticosteroid control. 2

Adjunctive Therapies for Severe Pruritus

• Sedating antihistamines may help with nighttime itching through their sedative properties, not through direct anti-pruritic effects. 1, 2
• Use primarily at night while asleep; avoid daytime use. 4
• Non-sedating antihistamines have little to no value in dyshidrotic eczema and should not be used. 1

Alternative Topical Agents

• For lichenified eczema, consider ichthammol (1% in zinc ointment), which is less irritant than coal tars. 2
• Coal tar solution (1% in hydrocortisone ointment) is generally preferred to crude coal tar and does not cause systemic side effects unless used extravagantly. 2

Treatment for Refractory Disease

Phototherapy

• Oral PUVA therapy has shown significant improvement or clearance in 81-86% of patients with hand and foot eczema and is superior to UVB in prospective controlled studies. 2
• Narrowband UVB may be considered, showing a 75% reduction in mean severity scores with 17% clearance rate. 2
• Topical PUVA has shown mixed results with less convincing efficacy compared to oral PUVA. 2
• Long-term concerns exist about premature skin aging and cutaneous malignancies, particularly with PUVA. 1

Emerging Biologic Therapy

• Tralokinumab, a fully human monoclonal antibody that neutralizes interleukin-13, has shown efficacy in severe dyshidrotic palmoplantar eczema in case reports. 5
• This represents a potential option for severe, refractory cases, though more evidence is needed. 5

Last-Resort Options

• Low-dose external beam radiation therapy has achieved complete remission in severe cases refractory to multiple topical and systemic agents, with durable response at 6 months. 6
• This should only be considered when all conventional therapies have failed. 6

Critical Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given concurrently. 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible to minimize side effects. 1
• Avoid very potent corticosteroids on thin-skinned areas where risk of atrophy is higher. 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly. 1
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment. 2

When to Refer or Escalate

• Failure to respond to medium to high potency topical corticosteroids after 4 weeks. 1
• Need for systemic therapy or phototherapy. 1
• Suspected eczema herpeticum (medical emergency). 1
• Extensive disease or diagnostic uncertainty. 4